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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> RtRftfffffiiiftifififfiffiftfiRfiRRtftitfffRRRRRRRtfiRRff RRIRRittfitRRRRRtRtfRRtiRifRRtRRRRiRRfRfifffiRRRRR <br /> SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be retumed to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: S I%• �-'0 V =E AVE l. i-Pb P� C.� of ra 330 <br /> TANK ID#39- 1 TANK SIZE: 1000 PREVIOUS TANK CONTENTS: Gw^QOt,-I"M <br /> ***********01656 D ***#**#*, **********************************************µ*dam**�************** <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: G W2-Y---w4 1 IJ G <br /> Address:_ CQ?417 19-1 A C:r 15�M J City: D-j FA,"-a" Zip: 04'��4t> <br /> Phone#: (92-JrP} 5 S 1, '1�i�j rj Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: �) <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: ( } <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/22/10) q <br />